Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Hunter Holmes McGuire VA Medical Center, Richmond, Virginia

Report Information

Issue Date
Report Number
16-00016-241
VISN
State
Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a review of the Hunter Holmes McGuire VA Medical Center’s Community Based Outpatient Clinics (CBOCs) and other outpatient clinics to evaluate for safe, consistent, and high-quality health care. The review evaluated the clinics’ compliance with selected VHA requirements for home telehealth enrollment, outpatient lab results management, and post-traumatic stress disorder care. We also randomly selected the Fredericksburg VA Clinic, Fredericksburg, VA, as a representative site and evaluated the environment of care on February 2, 2016. OIG noted opportunities for improvement and made 12 recommendations in the following focused review areas: Home Telehealth Enrollment, Outpatient Lab Results Management, Post-Traumatic Stress Disorder Care, and Environment of Care.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that contracted Environmental Management Service employees at the Fredericksburg VA Clinic receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the clinic manager ensures that Fredericksburg VA Clinic contracted Environmental Management Service employees receive the required hazardous communications training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the clinic manager reviews the Fredericksburg VA Clinic's hazardous materials inventory twice within a 12-month period.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Fredericksburg VA Clinic manager provides feminine hygiene products and disposal bins in women's public restrooms.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians document verbal informed consent for Home Telehealth services.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensures that the facility¿s written policy for the communication of laboratory results includes all required elements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.